Research

Could Online Reddit Discussion Groups for Individuals with Opioid Problems be Therapeutic?

Requesting and receiving support online may offer opioid users support that shares some of the therapeutic elements of group therapy. The responses to anonymous posts on a forum for individuals with opioid problems virtually always contained the types of comments that are believed to promote recovery.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Available technology means that opioid users who are not ready for engagement in treatment may explore their ambivalence about opioid use anonymously online before seeking in-person help. Online communities can also be adjuncts to professional help or form an integral part of a recovery plan. Given that so little is known right now about their potential benefits, we can describe them as innovative services making use of online platforms with limitless reach and “24/7” access that may help fill several types of roles for individuals with opioid misuse or opioid use disorders.

As we seek to establish the potential benefits of online forums, understanding the demographic and clinical profiles of those who use these communities and the types of exchanges that occur could be useful. This study attempts to first characterize the opioid use severity of the users of an online forum focused on opioid use, and then second to categorize the potential utility of the community’s responses to the users’ posts using a group therapy theory framework.

HOW WAS THIS STUDY CONDUCTED?

The authors maintained the anonymity of the Reddit forum (with 5000+ subscribers) and referred to it instead as an Opiates-Focused Forum or OFFopiates. They catalogued the first 100 ‘hot’ posts on Aug 19, 2016 (a Reddit algorithm filters posts to the ‘hot’ tab based on the number of up and down votes a post receives) and the corresponding 524 comments made directly in response to those 100 posts.

MORE ON STUDY METHODS

The research team developed a codebook to quantify the 11 symptoms of Opioid Use Disorder based on the criteria established in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). They characterized both the individuals posting and those commenting as having mild (2-3 symptoms), moderate (4-5 symptoms) or severe (6+ symptoms) opiod use disorder, as well as classifying them as current users (use within 48 hours), withdrawing (sober less than 30 days) or recovering (sober more than 30 days). They coded the posts for 10 pre-identified themes (relapse concern, seeking medical/professional help, seeking advice/support from either a friend/partner or from the subreddit members, worry about the negative effects of opiod use, use of other illicit drugs, mentioning their source of opiods, and discussing the usefulness of the Reddit forum). They classified the comments as having one of four distinct therapeutic factors characteristic of group therapy (instillation of hope, validation or universality, imparting information/advice, and altruism which included the sharing of personal stories). The coding and classification was done independently by three members of the research team and then reconciled.

WHAT DID THIS STUDY FIND?

Virtually all of the comments made in response to the 100 posts analyzed had a least one of four therapeutic factors common to group therapy theory. There were 511 distinct comments made by 183 unique authors (they excluded comments made by the post authors themselves) and 95% were classified as therapeutic (at least 1 factor), with 31% including two therapeutic factors, 14% with three factors and 5% with all four factors (instillation of hope, altruism, validation/universality, information/advice). Only 1% contained bad or potentially harmful advice. Thus, an organically grown online community naturally elicits from their interactions the type of responses that appear to make in-person group therapy successful and appears generally unharmful despite not being moderated by a professional.

Only 15% of the 100 analyzed posts made any reference to seeking help by a medical or substance use professional. The barriers to care that were identified included fear of workplace retribution, cost, other psychiatric disorders such as depression or anxiety, social isolation, stigma, or disruptive social circumstances. This suggests that this online forum is providing support to some opioid users not ready or able to access medical care.

Online forum posts can potentially be used to diagnose people and sub-type them by severity using standard medical criteria. However, only about a third of the posts or the comments could be classified by the opioid use severity or recovery stage of the authors. Of those that could be classified, the majority of the classified posters had mild opioid use severity (16 of 24), and only 1 had high severity. Approximately 20% of those posting were determined to be currently using opioids. Those making the comments were less likely to be actively using, with 27% of comments made by individuals in recovery, 15% by those in withdrawal and 3% made by authors currently using opioids as per the comment content. Thus, online anonymous forums may be a therapeutic aid useful for those with milder severity or not actively engaged in recovery yet who are not likely to be seeking in-person care.

WHY IS THIS STUDY IMPORTANT?

Anonymous online forums are being used by opioid users to obtain and provide mutual support and may be particularly useful to those without access to, or who are ambivalent about, in-person treatment, or those who have a milder opioid use disorder. As a resource for the recovery community, online forums are broadly accessible geographically, available around the clock, and can be accessed by the vast majority (limited only by computer or smartphone access) free of charge. This study shows that the exchanges between online forum members mirror the types of exchanges seen and validated in in-person group therapy and 12-step programs. The comments made by community members are virtually always supportive and appear very rarely to undermine recovery. This study suggests online forums (particularly anonymous ones) may be an additional therapeutic tool, that might be suggested to individuals to obtain more opioid-specific recovery information and support, and to explore ambivalence about change, particularly for those not ready or able to engage in in-person care.

LIMITATIONS

The responses were catalogued for potential clinical utility but given the study design, one cannot determine the therapeutic effect of online forum engagement.

Only the posts or comments up on a single day on a single forum were analyzed

Reddit users are predominantly males aged 18-29 so these findings may not be generalizable outside of this group

Though this study aims to distinguish itself from other studies of online forums by characterizing those making posts and comments using DSM5 criteria, only a minority (approximately 30%) could be classified by the details included in their postings.

In terms of classification of severity, those mentioning only one symptom could actually have more severe use and simply have only mentioned one of the many symptoms they are experiencing those mistakenly skewing the analysis towards milder use disorder.

NEXT STEPS

This study is not designed to analyze the beneficial effect of online forum engagement in promoting opioid recovery. Researchers should explore the inclusion of online anonymous support in their studies of different interventions to determine its effectiveness either together with, or instead of, more traditional and researched forms of substance use disorder treatment. Including online support in outcome studies of treatment could help determine if online communities are comparable to in-person support groups for supporting recovery, and for which groups they are most useful (for example, mild as opposed to more severe opioid use). In addition, scientists should study the role that anonymity plays in enhancing truthful exchanges and perhaps promoting more effective engagement in treatments.

BOTTOM LINE

For individuals & families seeking recovery: Anonymous online forums are already being used by substance using individuals who may not be ready for in-person care, and may allow them to be more open and honest about the extent of their use. This study is not designed to determine whether engagement in these forums promotes recovery but does suggest that the types of exchanges on these forums mirrors the therapeutic aspects seen in in-person group therapy treatments as well as face to face mutual-help group participation such as AA and NA. (link/cite Labbe systematic qualitative paper here in DAD).

For scientists: This descriptive study utilized an innovative (but labor intensive) method for analyzing the content of individual posts to identify clinical characteristics of the participants. As it analyzes a single day on the forum, it cannot speak to the role online engagement plays in recovery. The study of anonymous engagement vs in-person care in randomized trials (in combination or head-to-head) may shed insight on the role of shame in limiting honesty with self or others as an important barrier to care.

For policy makers: This study cannot speak to the clinical benefit obtained from engagement in online forums for opioid users. However studying clinical effectiveness of this type of online engagement would be a worthwhile priority given the widespread appeal of online forums and its accessibility regardless of geography. Validating online substance use forums may provide a low-cost, widely applicable treatment modality at a time when access to treatment is constrained by availability and high demand.

For treatment professionals and treatment systems: Online forums can be included together with validated treatment interventions, although this study cannot speak to their clinical effectiveness. The benefits of anonymity of online forums could open a new avenue of intervention that complements and broadens the reach of current treatment approaches. Incorporating this intervention into standard treatments could prove cost-effective and broaden access to care if further validated in randomized controlled trials.